When it comes to medical legal liability, we all know the system is broken. Risk in the emergency department, of concern both to practicing physicians and administration, is no exception. Add emergency care for children into the mix, and the level of concern increases even more. The good news is that the vast majority of children present without life-threatening illnesses or injuries. However, when care doesn't go well, when adverse outcomes happen, parents' anxieties and tensions rise significantly and quickly. And with them, so do risks of legal action.
Is there anything you can do to minimize your risk surrounding emergency care for children? The answer is a definite "yes!" While you cannot dodge all the bullets, you can significantly reduce the chances of needing a discussion with your friendly lawyer by taking proactive measures today.
Follow these four guidelines to dramatically decrease legal risk:
- Provide excellent pediatric emergency care.
While obvious, providing excellent care is not necessarily easy. The first question that arises when reviewing care is whether the "standard of care" was met. Unfortunately, the standard of care is not absolute. For example, a children's hospital serving as a Level I Pediatric Trauma Center is expected to provide a higher level of definitive care to a seriously injured 3 year old than is a small community hospital. However, both hospitals are expected to meet a certain minimum level of trauma support and to provide a certain minimum level of stabilization for that child.
Community emergency departments, by their very nature, typically see fewer children than do larger, urban centers. And overall, children tend not to become as seriously ill or injured as do adults. As a result, most community hospitals have significantly less experience with very sick children. It is therefore essential that community providers of emergency care for children commit to ongoing pediatric clinical education.
Journals, such as Pediatric Emergency Care or Clinical Pediatric Emergency Medicine provide case-based studies of common problems that arise in the emergency care of children. Conferences through a variety of regional and national medical organizations offer opportunities to learn about and discuss challenging cases. Local courses may be arranged for both physicians and nurses, with a focus on the practical aspects of pediatric emergency care. The key is to establish a commitment to continuing education in pediatric emergency care.
- Communicate well with children and families.
"Patients don't sue people they like?" - from the TV show ER (April 8, 2004)
While excellent communication has long been recognized as an important factor in reducing medical legal risk, communication with families is particularly critical. Parents are often anxious as they enter the emergency department. Their perception, right or wrong, is that their child is sick or hurt enough to require emergency care. Parents will sense your level of concern and caring seconds after they arrive. In fact, their opinion and bias towards the anticipated level of care to come was formed long ago in triage and registration.
Does your department or practice send out welcoming "we're here to help you" vibes when families arrive? Or do parents get the subliminal message (or perhaps not so subliminal) from staff that "another problem" just came in? I've seen it both ways, and am amazed at how much better perceived care (and often actual care) is in the first, welcoming environment. Creating positive initial impressions during triage and registration sets the stage for positive experiences with physicians and other providers. It is then essential that everyone providing clinical care take time to listen to the child and/or parents' concerns, and reflect those concerns back in a way that makes it clear they are heard--and understood.
Most encounters are fairly straightforward. But when unexpected problems arise, whether it's a long wait for a consult or an adverse outcome, take time to explain to parents (and the child, when appropriate) what is happening. The reality is that these encounters often can be quite brief, so time is not usually an issue. The simple goal is to establish a truly human connection with the family. Communicating and demonstrating that you care is a great step forward in that direction and goes a long way in reducing potential medical legal problems that may arise much later.
- Document with care, and care about your documentation.
"If it isn't written down, it never happened." This is "well-documented" advice related to medical charting. Every physician who has had the unfortunate experience of facing a legal action knows how absolutely essential chart documentation is to defending patient care. And yet, in reviewing many pediatric charts, both for quality improvement and medical legal reasons, I am dismayed by how frequently I come across sloppy or inadequate documentation. Illegible handwriting, missing key elements and inadequate descriptions of physical findings are just a few of the common problems I regularly encounter. These discrepancies are likely to come back to haunt a physician if subsequent problems arise.
Since children are an especially vulnerable population, the care surrounding pediatric emergencies faces particularly close scrutiny. The best way to ensure proper documentation is to document care as if the case is going to have unexpected, adverse clinical outcomes that will require your attendance at trial two years down the road. You may, or may not, even remember the case two years later, so it is vitally important to document, in black and white, everything you would want a lawyer or jury to know. Essential elements include:
- Times the patient is seen, as well as times that labs, procedures and reassessments are accomplished. This is essential, but often missing.
- Vital signs (and repeat vital signs, as needed), including how and when abnormal vital signs are addressed.
- A brief description of the patient's general appearance. Noting "normal" is not adequate. Use terms like "well-appearing," "interactive," and "smiling" to paint an image of a child who is not ill-appearing. The word "lethargic" is over-used, and suggests a seriously ill child requiring critical care.
- Specific areas of concern expressed by the parent, including relevant discussions (e.g., if a parent is concerned about appendicitis in a child with a benign abdomen, briefly document this concern and that it was appropriately addressed).
- Timely and appropriate follow-up for all patients.
Establish a culture supporting medical legal risk reduction.
Excellent chart documentation does not take place in a vacuum. Administration must support the effort and colleagues must recognize that documentation is important for everyone. Many methods exist to help you document care, ranging from handwritten charts and dictation to template and electronic systems. While a review of these systems is beyond the scope of this newsletter, it is essential to explore how these methods help capture, or impede capturing, clinical information for medical legal documentation. In addition, chart reviews, as part of a quality improvement program, are very helpful in identifying and addressing documentation issues.
Stepping back from documentation, it is important to create an environment which supports excellence in emergency care for children. Establishing a practice or emergency department environment that truly expects the best for the children it serves means ensuring that all providers are "up to speed" on best practices for children. It means everyone is aware of how critically important communications are when it comes to children and families--not just for reducing medical legal risk, but for providing great care and service. In short, focusing on excellence as it relates to providing care for children will translate both into reduced medical legal risk and improved pediatric emergency care for the children you serve in your community.